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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 4 of 4. This is the beginning of the thread.
Posted by Racer on June 4, 2004, at 11:33:35
My husband and I need to choose from two insurance options offered by his new job: HMO or PPO. The PPO has a six month pre-existing condition exclusion, the HMO has none. Since I'm uninsured, it would seem like a no brainer, wouldn't it? It's not. I really distrust what I read on the company's website about their "Managed Behavioral Health" program:
1. Decisions about what care is appropriate are made by a Customer Service Representative after a "Clinical Evaluation" done by that CSR via telephone. The CSR then authorizes a certain treatment plan and then refers you to a provider from their list of providers who comply with the company's "Problem-focused, results-oriented" treatment guidelines.
2. The website describes their network as being closely monitored and supervised by the insurance administrators to ensure compliance with their guidelines.
3. There's a little glitch that allows prospective members to read something directed at employers regarding 'cost consciousness' in the care guidelines. In other words, they do have something in writing that specifies that they keep their costs as low as possible by offering short term treatment models through their network.
Basically, aside from being more than a little freaked out by the thought of a CSR deciding my treatment plan rather than a doctor, it looks to me as if I'd be better off waiting the six months for the PPO mental health exclusion to pass than going the HMO route and having to wait up to 12 months for an open enrollment period so that we can change over. My husband strongly disagrees. (He's never experienced an HMO, and his pre-existing condition -- diabetes -- is not subject to exclusion.)
I'm willing to admit that I'm not in a state to see this issue very clearly. To me, right now, it just looks as if I'd be going from bad to worse, with less chance of it improving within anything like a reasonable period. During the six month period, I would be eligible for other services through the PPO, which could include things like getting my meds even if they don't help, so the PPO would provide an immediate benefit.
Anyway, I wanted to hear some other perspectives on this issue. (But remember that I really am pretty fragile right now -- that is an issue regarding the care I receive: if the care went from the "Not Good" that I'm getting now to "Even Worse" under the HMO, I'm not sure I could survive that. At least now, if we take the PPO, I know that in six months we can look forward to things changing and probably for the better. Maybe that's not enough to make it worth the wait, but it really feels that way to me.) So, anyone have any scathingly brilliant insights into this dilemma?
Thank you very much.
Posted by lucy stone on June 4, 2004, at 13:24:08
In reply to Seeking advice re: insurance, posted by Racer on June 4, 2004, at 11:33:35
Is there any way you can pay for it yourself out of pocket? Does your employer offer medical savings accounts? My insurance covers 15 therapy visits/year with an option of 9 more with approval. I use that up in no time but my medical savings account helps. The program offered by my employer allows me to put money away pre-tax that I can use for medical expenses. My husband has the same and can use his money for my expenses. In our tax bracket the reduction in our gross income gives us a tax saving that brings the cost of my appointments down by approx. 1/3. Maybe something like that would be enough to allow you to pay out of pocket for the 6 months you would have to wait because of your pre-existing condition.
Posted by TexasChic on June 4, 2004, at 14:17:50
In reply to Re: Seeking advice re: insurance, posted by lucy stone on June 4, 2004, at 13:24:08
I have that medical savings plan at my work too, its called the cafeteria plan. What's great about it is you can borrow from the total you *will* put in during the rest of the year, even if you haven't contributed that much yet. The bad thing is you have to use it or lose it.
As far as your HMO PPO dilemma, do you know for sure the PPO doesn't have the same of similar restrictions on mental health costs? I would make sure of that before I decided anything. If it doesn't, I would definately go with the PPO. The thing about the CSR's deciding on your treatment is ludicrous. But that's what our healthcare system is coming to. (sigh...)
Posted by jane d on June 4, 2004, at 22:37:41
In reply to Seeking advice re: insurance, posted by Racer on June 4, 2004, at 11:33:35
I swore off HMO's after I had a ridiculously long wait to be seen on a fairly urgent matter. With my PPO when I think I've waited enough weeks or months I can just go to a non preferred provider and pay a bit more (strange how there seems to be less delay this way). The PPO also lets me keep a few doctors I like who are not on my current insurance plan. This ends up costing more though, so if the money absolutely isn't there it's silly to pay higher premiums for a feature you can't use.
Your mileage may vary disclaimer time: Insurance (with the exception below) is regulated by state law. Your state has different rules from mine. And even with in the same state, the same insurance company will offer plans with slightly different terms. Check the terms of yours with the employer. And no, it is definately not fun to call up human resources to ask whether or not they will pay for your psych care. Well..... I guess it COULD be fun.
Beware. The PPO's I've dealt with can also have limits on mental health and often do. They may limit the total number of visits in a year to 20 or 30 but leave it totally up to you how you use them or they may also require you to get preapproval from one of their cost cutting CSRs. Probably the same one they use for the HMO. Definately something to check in advance.
I never did try to get mental health care when I had an HMO. Basically I was #(*@#@#A if I was going to call up to get permission from a gatekeeper. And at the time I needed the help I probably wouldn't have been able to navigate that system either. I've been following your posts and you seem to be a far more effective advocate for yourself and might be able to make it work.
The other problem with HMO's that I've heard of from other people is that they had major problems finding someone who was actually in the HMO's plan. Lots of entries in the HMO directory were long since departed for more prosperous pastures or weren't taking in any more patients. If there's no one acceptable in your area who is actually in the plan (as confirmed by the provider of course) then your decision just became really easy.
One last thing to keep in mind. So far there is no federal mental health parity legislation requiring insurance companies to give the same benefits for mental health. Some states do have have parity legislation - I think yours may be one - but employers who self insure are not bound by the state rules. These are companies that are taking the financial risk themselves and just using an insurance company to do the management and it's something that only the big guys are going to do.
I wish I could be more help. Good luck.
Jane
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